Ar_ vol. 7 issue 4_ p. e227

Fungal rhinosinusitis (FRS) can be divided, by histopathologic evaluation, into invasive and noninvasive types. Signs of fluid in ears Noninvasive FRS can be further classified as eosinophilic (including allergic FRS) and sinus fungal balls (FB). Relieve fluid in ear 1 The clinical course for these disorders is varied and ranges from indolent to potentially fatal. Fluid behind eardrum adults Management differs based on the diagnosis, although surgical intervention is necessary for diagnosis and treatment. Fluid in baby ears The pathologic evaluation of paranasal sinus FB reveals fungal hyphae that fill the sinus interior but lack mucosal invasion.

Fluid behind eardrum remedy The most common reported location for FB is the maxillary sinus, 2 , 3 followed by the sphenoid sinus. Fluid behind eardrum symptoms 4 Presenting symptoms for FB are dependent on the location of the pathology and can also be incidentally identified on imaging studies in patients who are asymptomatic. Fluid in the ear symptoms 3 When the sphenoid sinus is affected, headache, nasal obstruction, and visual disturbances are the most common presenting symptoms. Feeling of fluid in ear 2 , 3

The proximity of the sphenoid sinus to surrounding critical structures, including the internal carotid artery and the optic nerve, can result in significant complications from sphenoid sinus disease. Home remedies for fluid in ear Several studies describe sphenoid sinus wall erosion and SSFB 5 – 9; however, reported complications from SSFB are limited in the literature. Fluid buildup in ear 4 , 8 , 10 – 12 Previous case series demonstrate that endoscopic sinus surgery (ESS) for removal of SSFBs is an effective treatment and that systemic antifungal therapy is not necessary. Middle ear effusion symptoms 4 , 5 , 8 , 11 , 12 However, the incidence and management of patients who present with complications of SSFB has not been specifically studied. Ear pain and headache on left side Given the limited nature of published reports, the purpose of this study was to review our institution’s experience with SSFBs, including the incidence and management of intracranial or orbital complications.

A retrospective review was performed of all the patients who underwent ESS for SSFB from 2006 to 2014 at Massachusetts Eye and Ear Infirmary. Fluid behind eardrum treatment Clinical data, including age, sex, the presence of orbital or intracranial complications, radiologic data, surgical management, microbiologic and pathologic results, and the postoperative course were extracted from the medical record. Ear and throat pain on one side Skull base erosion was defined as radiographic evidence of loss of bone within the sphenoid sinus. Middle ear effusion treatment The institutional review board at the Massachusetts Eye and Ear Infirmary approved this study. Get rid of fluid in ear J.C. Fluid in ear toddler Meier and G.A. Fluid in ear from allergies Scangas contributed equally to the manuscript.

All the patients underwent preoperative evaluation with rigid nasal endoscopy and computed tomography (CT) imaging. Ear and tooth pain Magnetic resonance imaging was ordered in four patients in whom there was concern for a possible neoplasm, patients who presented with an orbital or intracranial complication, or if there was extensive orbital involvement or skull base erosion. Left ear and jaw pain The patients underwent ESS with a wide endoscopic sphenoidotomy (transnasal or transethmoid), with removal of the fungal debris. Fluid build up around the heart All the specimens were sent for histopathologic evaluation. Fluid on eardrum Bacterial and fungal cultures were sent in 78.0 and 42.0% of cases, respectively. Fluid in ears adults Patients with evidence of purulence in the sphenoid sinus during surgery were discharged home on broad-spectrum antibiotics. Cervical mucus in early pregnancy Nasal saline solution irrigations were instituted on postoperative day 1. Sinus fluid in ear Endoscopic debridement was performed 1 week after surgery and repeated if necessary.

Sphenoid sinus disease can result in significant morbidity due to the proximity of adjacent structures, including the cavernous sinus, carotid artery, and optic nerve. Inner ear fluid in adults Sphenoid sinusitis can be due to bacterial or fungal infection, and the possibility of invasive fungal sinusitis should always be considered, especially in patients who are immunocompromised and present with acute complications of sinusitis. Cervical mucus in early pregnancy pictures Visual symptoms, including vision loss and diplopia, can often be the initial presenting symptom of a sphenoid process. Leaking clear fluid during pregnancy In a report of 13 patients with visual disturbance secondary to isolated sphenoid sinus disease (including four patients with SSFB), the optic nerve was the most commonly affected cranial nerve (54%), followed by the sixth cranial nerve (40%). Water retention early pregnancy 13 Only three of eight patients who presented with visual loss in that study had improvement after surgical management of the sphenoid disease. Leaking clear fluid early pregnancy 13 Pagella et al. Chronic fluid in ear 4 reported eight patients with SSFB who presented with blurred vision, blindness, and diplopia. Clear mucus discharge during early pregnancy Six patients recovered after surgery; however, there was only 60% recovery in patients with optic nerve involvement; the one patient who presented with unilateral blindness did not recover. Clear discharge during early pregnancy 4

Another series of patients with SSFB identified five patients with orbital complications, including two patients with vision loss and three patients with diplopia. How to get rid of fluid in ear 8 Although the diplopia resolved in all the patients, the two patients with vision loss did not have any recovery in visual function. How to get rid of fluid in the ear 8 In our series, the patient who presented to our institution four days after complete loss of vision did not recover vision after surgical intervention. Fluid trapped in ear Thus, prompt diagnosis and treatment are imperative in the hope that the presenting visual complication can be reversed. Fluid in eardrum Although less common than orbital complications, other sequelae of SSFB have been reported. Fluid in ear symptoms adults Schlosser et al. How to get rid of fluid behind the eardrum 11 reported one patient with internal carotid artery thrombosis, and, similar to the patient in our study, deShazo et al. Clear watery discharge early pregnancy sign 10 reported two patients with new onset seizure in the context of newly diagnosed SSFB. How to relieve fluid in ear 10 In this series, after surgical intervention, the patient who presented with a new onset seizure had complete recovery, with no further seizure activity and a completely normal neurologic workup. Dry cervical mucus early pregnancy Interestingly, in our study, 13.1% of SSFB were discovered incidentally, comparable with other reported studies (8.9%, 3 20.7% 5). Fluid behind the eardrum It is important to consider that, given the severity of potential complications of untreated SSFB, surgical exploration and removal are warranted, even in asymptomatic cases of SSFB. Ear pain and sore throat The potential development of orbital and intracranial complications should be specifically discussed with patients when considering treatment options once this disorder has been identified on imaging studies.

The pathogenesis of sinus FB remains unclear. Cervical mucus early pregnancy In cases of maxillary sinus FB, several studies implicated the transgression of dental material into the maxillary sinus via an endodontic procedure as a potential instigator of mucosal damage and subsequent fungal growth. Fluid in middle ear symptoms 14 – 17 Nicolai et al. Draining fluid in ear 3 noted that 104 of 120 patients (86.7%) with maxillary FB in their study had previously undergone endodontic treatment of a maxillary tooth. Fluid in inner ear However, this history was not noted in patients with SSFB. Ear and jaw pain on left side 3 Lee et al. Fluid behind eardrum in adults symptoms 13 presented a case series of patients with sphenoid sinus disease with visual disturbances (4/13 with SSFB). Remedy for fluid in ear Of these, five had previously undergone sinus surgery (four via Caldwell Luc, one via endoscopy) and one patient had undergone transseptal sphenoidotomy for resection of a pituitary adenoma. Fluid in ear remedy 13 Interestingly, in our current study, 16 patients (37.2%) had undergone previous sinonasal surgery. Fluid in your ear Of these 16 patients, 11 underwent previous sphenoidotomy (4 underwent transsphenoidal pituitary surgery and 7 underwent ESS). Fluid in ears allergies The high percentage of patients with SSFB who had undergone previous sinonasal surgery may be a risk factor for SSFB, although, at this point, the exact mechanism remains unclear.

A noncontrast CT should be the initial imaging modality to evaluate FRS. Symptoms of fluid in the ear Findings on CT that are suspicious for FB include the following: hyperdensity or calcifications within the sinus, and hyperostosis or erosion of the surrounding bone. Sinus drainage in ear 18 , 19 In our series, a hyperdensity or calcification within the sinus was seen in 72.9% of the patients, and hyperostosis of the walls of the sphenoid sinus was noted in 74.4% of the patients. Ear and tooth pain on one side In addition to reviewing the imaging studies to predict the diagnosis of SSFB, the CT should be closely reviewed in preparation for surgical exploration. Fluid in ears in adults A history of endoscopic sphenoid sinus procedures, including ESS or transsphenoidal pituitary surgery, remains imperative because the anatomy can be significantly altered. Ear and jaw pain after tooth extraction The presence of skull base erosion should also be noted. Fluid in the ear in adults Forty percent of the patients in our study were noted to have skull base erosion on initial imaging studies. Fluid in ear symptoms in adults There was a higher rate of complications from SSFB seen in patients with skull base erosion compared with patients without skull base erosion, although it did not reach significance (11.7 versus 0%, respectively; p = 0.151).

Both of the patients in our series who presented acutely with intracranial or orbital complications were noted to have skull base erosion on initial CT. Jaw pain on left side near ear This finding was seen in another series, in which there was a significantly higher rate of sphenoid sinus wall erosion in patients with orbital complications compared with those without orbital complications (100 versus 36.3%). Symptoms of fluid in ear 8 Only one previous study of SSFB specifically commented on the incidence of skull base erosion 11; however, other studies did note percentages of patients with erosion of sphenoid sinus walls, which were 13%, 5 16%, 6 25%, 7 48%, 8 and 52%. How to get rid of fluid in inner ear 9 Although skull base erosion can be suggestive of a more ominous diagnosis, in our series (39.5%) and in others, it was commonly seen with SSFB. Fluid in ear symptoms Magnetic resonance imaging can be obtained as an ancillary study in patients with acute orbital or intracranial complications of sinusitis or if the diagnosis is not certain. Ear jaw and neck pain on left side FBs can have variable T1 intensity; however, they predominantly have a low T2 signal, which can aid in identifying this disorder. Signs of fluid in ears 20

Once SSFB was suspected, the treatment algorithm for these patients involved prompt surgical exploration. Relieve fluid in ear The two patients with intracranial and orbital complications underwent surgery emergently. Fluid behind eardrum adults An important principle of surgical management remains adequate exposure for complete removal of all fungal debris. Fluid in baby ears In cases of isolated sphenoid sinus involvement, endoscopic transnasal sphenoidotomy alone can often achieve adequate exposure and was performed in 23.3% of the patients in our study. Fluid behind eardrum remedy In patients with limited transnasal access or involvement of the ethmoid sinuses, an endoscopic transethmoid sphenoidotomy approach can be performed (76.7% of cases in our study). Fluid behind eardrum symptoms Seven patients (13.7%) underwent a more-extensive surgical sphenoidotomy, with either drilling of the face of the sphenoid or sphenoid nasalization 12 to ensure adequate exposure of the sphenoid sinus with complete removal of fungal debris. Fluid in the ear symptoms Although no cases of intraoperative cerebrospinal fluid leak were noted in our cohort, surgeons should be prepared to address this possibility at the time of surgery, especially in patients in whom skull base erosion has been noted on preoperative imaging studies. Feeling of fluid in ear In this series, the patient who presented with unilateral blindness recovered uneventfully after surgery but did not regain any vision. Home remedies for fluid in ear The patient who presented with an acute seizure recovered uneventfully, without further neurologic sequelae.

Histopathologic evaluation to confirm FB and to rule out invasive FRS is imperative for the final diagnosis of this disorder. Fluid buildup in ear In patients with a history of immunosuppression or diabetes, the diagnosis of invasive fungal sinusitis is especially important to ascertain in a timely fashion. Middle ear effusion symptoms In all cases in our series, histopathologic evaluation showed a large volume of fungal hyphae without evidence of sinonasal mucosal invasion. Ear pain and headache on left side Operative cultures were much less sensitive for identifying fungus, with only 4 of 21 cases that resulted in a positive culture, as has been noted in other studies. Fluid behind eardrum treatment 3 , 21 Ultimately, the diagnosis is dependent on the histopathologic presence of fungal forms rather than microbiologic evaluation. Ear and throat pain on one side Limitations of the study included the retrospective nature of this review and the small number of patients with complications of SSFB in our series. Middle ear effusion treatment Large series of SSFB are not commonly reported, and this review added to the body of literature on this uncommon disorder. Get rid of fluid in ear It is important to recognize that skull base erosion is frequently seen in this disorder and that orbital and intracranial complications of SSFB can occur and can result in permanent deficits if not recognized and treated.

SSFB is a rare entity, which often presents with nonspecific symptoms or which is identified incidentally on imaging studies but can cause potentially severe complications, including permanent visual loss, given the critical structures that surround the sphenoid sinus. Fluid in ear toddler Skull base erosion is frequently seen as a consequence of SSFB and should be specifically assessed before surgical exploration. Fluid in ear from allergies Endoscopic surgical removal of the SSFB is necessary for management and should be performed in an emergent fashion for patients who present with significant complications, especially when the optic nerve is involved because visual loss is often not reversible.